Healthcare Provider Details

I. General information

NPI: 1710937446
Provider Name (Legal Business Name): RICHARD E O'BRINGER JR. PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11413 PERUGINO DR
LAS VEGAS NV
89138-1533
US

IV. Provider business mailing address

11413 PERUGINO DR
LAS VEGAS NV
89138-1533
US

V. Phone/Fax

Practice location:
  • Phone: 702-499-7296
  • Fax: 702-254-9190
Mailing address:
  • Phone: 702-499-7296
  • Fax: 702-254-9190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA626
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: